20060 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY 1V
Buildir,Prejeok IdentifiWion / p P TNo..
Building Addrme o: y- _ ` 20060
Z3 7 oln TTW �.JIJI
n<r. . phone. APPLIC_ATICN SUBMITTAL DATE
CITY OF CUPERTINO-BUILDING DIVISION
•
meName: Ge Na APPLICATION / PERMIT
/�` Z BUII.DINGQ,DCTRICAJ_PLUMBINGMFLHANICAL CATEGORY CONTR LN
Archite tEeglneer
'1- G — QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add— 0q ff 1 . s [ I'FRh9TISSUANCE ❑ F-1 ❑
LICENSED CONTliACTORS DECLARATION
I hereby affirm that l am keen d!under pne,l.lans of Chapter 9(mmmam APPLIANCESRJESMENTM, JOB Df'JCRE'fi
ON
licer.h inhil7000)ofddf:T3ofthe B dlsro/e,lon.Code,end I ^ /� (1�
Ifmnse lalo/ulWnq and dfect PANELS
LlrenseC ee 1. (^A LTH. �, k e _
Date CnntnRorUP TO 2DQAMPS
ARCHITBCPSDECLARALION 1ERIOM PS AM
nuerG Iundenteod my plane shall he used as public nemesia OVER 1000 AMPS FT. A $/90.FT.
- 2 Licensed Prvfmb OSIGNS ELECTRICALE �
WNER-BNLDER DECLARATION
7t, 7 Ihereby affirm that Ienexempt from the CoMrxtor3Llaruelaw for the
SPECIAL G,RGDIT/ UTE R
Fg 'p❑� following mxaon.(Sectim�70315,Buerm and Professions Code:Any my or
� aantywhkhmryl aper tomrutruct,alter,lmpm ,demolbh,ormpalr TEMP.METER ORPOLE INST.
any gmm prior to its bourne,also requlw the appBunt for euro permit to—.POWER DEVICES
file a signed statement the he b 1lenacd pumunt to the provision of the
3w Contrnorb Licenx Law(Chapter 9(memrcndng with Setlon 700))of DN4 SWIMMING POOL ELECTRIC VALUATION
X05 sbn3oftM1e Budnmand lsmfesloruCde)orthat hebevemptthere[romad _
the bub for the alleged eaemptbn. Any violation of Section 7MI5 by any
appliantfora peso mbkcutheappB ttoadvlpenaltydno more Hun OUII-ESSYIILHFSFLXTURES
nve hundred dWbn(x900). NEW RESIDENTIAL ELDC,IR
�n p I,as owner of the property,or my employewith wages as their sole SFT. STORIES
TYPE CONSTRUCTION
< mmpc aatlm,wWdothe work and lheatnebare b not maimed or offered for
5 D
sale(sec.7054,Bmuinets and Professions;Code:The CoMranol,Llmme Lw
docs not apply to so owner of property who builds or improves thereon,and OCC.GROIIIs R6.UNITSCG. who doesauch work himself orthwgh hisownemplojce,provided Hut.6
improvcmew are not intended or offered for sale.If,hnvever,the building or TOTAL. '
improvement is within one yearofeaanpldbM1 the owner-buMerwBl have
the Ina rden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
Ll L as owner of the property,am erchaslvely mnvxUnghIkxnecd [•1,003 ZONE AI'N
PERMIT ISSUANCE
conte to mmtnid the project(See.70K lhialress and Professions Cad
The Com mors License law does not apply to an owner d property who ALTER-DRAIN kVFM-WATER(EA)
hrltds or improve theean,and who mmnm fee ache pPjem with a
cgD¢anor(aB¢ead an
purnt to the Curmelos.Lkamse law. BA«FLOW PROTI:YT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C far this rearm
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date RECFP'T
WORKMAN COMPENSATION DECLA RATION pD(TVIII:S I'FR 7RM 5(71001,TAX Y N
I hereby affirm that I have a certi" of consent to.elf-kwm,m a RECD N
rt oteof Worken''Compe ti.lruu.an .ce VW mpythemN(Sec. TO
GAS FA.SYSTETI-1 BJC40UlLE15 PARK FFP Y N
3800,Tab ) pp I p nn
Com Y Oy-I I a0 l O S Q V RECEIPT
GAS FA.SYSTEM-0VFR (EA)
y BUILDING DIVISION FEES
Cermed ropy b herefiled tumbhed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
I�CertBied ropy b flled'Mth Hee tlty Ivpenbn dfvWm.
/Y CERTIFICATE OF EXEMPTION FROM WORKERS GRF'aSE TRAP PAID
COMPENSATION INSURANCE
lithe pemrlt Lafmorc hundmd daBan SEWER-SAN(1.ARY-STORM FA 70(BrI Date Remi t#
• (TNeee tion need oat be completed
Rt l0 Aifes.) WATERHEATFRW/VENT/E1,ECTR - ENERGYFEE Y N
lamfythatln the person in
rewosksorwMNNl.pemdtla ba sed,
1 ori, not empenloy any person b any manner at u to berme aubfet to the WATER SYSTEM/TRFATING
w«iter:Compensation law.of aluamb.Date PAID
O Appli.
Z � rNUwTICncsro APPL1cANT:v,after mwng lnbcetBlate ori:semptbrm,yw NEw R19INI'I
DAI.PIMB. sQtr. Date Remi DY
ahanld heoome.ub7en toth.Worker;Compeovloe
eatlon prbofthe Labor - TOTAL
WCCN Code,yourwrt hwithmmplyymthwApmvbbvorthlspemd[ olbe
] deemed rooked. 5UILDING FEE
CL
O
CONSTRUCTION LENDING AGENCY S ISMIC FEE
Ihembyafnenthat then b.mstn,mon leming.genmcy for Hose pedamf .TOTAL ELECTRIC FEE
7 Z anoe of the workfor whpermit kh this peit b byed(See.3097,CN.C.)
O O lander',Nano PLUMBING FEE
LL ~ IcMesAddress QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W I Cer Rytlut l haw maitha
Lsappitbn and sbtethdmtl
the above lnfoum ^^
bmrmet.i,greetocomplywhaUdtyardmuntyordinanmandmatelaws PERMIT ISSUANCE lJ,00 FEFS PAID:
} IL relating in Wilding cerutrunler,and herebyautM1mb represntatNe ofthb
F Z myto cote upon t cnrntb rty fos lepMbn purposes. ALTER OR ADD TO MECFL
V _ (We)agree to ve, emNly d hurl the City of Cii,rmo Date Rotel tf1
eg.Wt Whim ,)rd b, and per msyinanyway.omm AIR HANDLING UNIT(TO 10,0D)CET() SUBTOTAL:
a ivt itY sego of gat his pemdL AIR HANDLING UNIT(OVER 10,0)0CEM) CONSTRUCTION TAX
Sig of Apphcant7C.trunm, Date E7DIAusr l-IClOD 3v/DUCT) CONSTRUCTION TAX PAID:
HAZA RDOUS MATERIALSnonapa tmomoSU0.E
Will theapplicant d6red by the up Cupertino Municipal
uore hhentkhavnthe HEATING UMT(T0100,0)0 BTU) Date Rmei tM
nutedalM Seery odthe $3jcm 252(x)? lCodaChapter 9.17,and the
Health and Safety Cade on 75537ta)7 HEATING UNIT(OVER IW,WO BTU) TOTAL: Q
Yes jjj No
Will the hard , tum WOdbgacapantu.y the Bay Am,
device r VENTILATION FAN(SINGLE REND) ISSUANCE DATE
whkh amt hevrdoua air mnlamnunta a de0vd by the Bay Ana Alr
• Qualuy hlanugament tW 7 �IIPRLOMP PHP OR 100,IX3 BTU) ias
Yee PAID
have read theh maerlab requirements under Chapter 6.95 of BOILMCOMP(OVIR 100,000 BTU) Aly
rhe OBfornlaHult fety Code, 75,505,75573 and 75534.1 JUL .
udmtad that c Bding does oily hav nanL that itbmy NEW RE9DFN77AL MECH. SQFT. 31.1990
resporo(bBlty oat ht occv sit require whkhnusthmet
P,to is Certl parry.
ar
n authadsd agent Date ��.m7I/���( L�J�t
TOTAL: ISSUED 6Y: jr,: .�t�� `�"`—'"•
OFFICE COPY